BVA9507253 DOCKET NO. 91-19 377 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Increased (compensable) rating for allergic rhinitis. 2. Increased (compensable) rating for asthma. 3. Service connection for an unspecified disorder of the hands, currently diagnosed as bilateral carpal tunnel syndrome. 4. Service connection for arthritis of the hands. 5. Service connection for arthritis of the elbows. 6. Service connection for an unspecified disorder of the elbows. (A claim on the issue of entitlement to educational assistance benefits under Chapter 30 is the subject of a separate decision.) REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William L. Pine, Counsel INTRODUCTION The appellant served on active duty from June 1963 to June 1989. The instant appeal is from the Department of Veterans Affairs (VA) Regional Office (RO) decisions of January and August 1990, denying compensable ratings for allergic rhinitis or asthma and service connection for a disability of the hands and elbows. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that the severity and persistence of symptoms of allergic rhinitis and the frequency and severity of asthmatic attacks makes each compensably disabling. He contends that he suffers a disability of the hands and elbows, either musculoskeletal or neurologic, that is the result of an injury sustained in the service. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file(s). Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that a preponderance of the evidence is against awarding a compensable rating for allergic rhinitis; a compensable rating is warranted for asthma; service connection for bilateral carpal tunnel syndrome is warranted. The appellant has not met his burden to submit evidence sufficient to justify the belief that his claims for service connection for arthritis of the hands or elbows or for an unspecified disorder of the elbows are well grounded. FINDINGS OF FACT 1. Symptoms of allergic rhinitis are well controlled with immunotherapy; there is not definite nasal atrophy and amount of secretions is less than moderate; there is no loss of time from work or reduction in work capacity due to allergic rhinitis. 2. Asthma causes labile reduction of pulmonary function, mild dyspnea upon exertion and slight reduction in functional capacity on the job. 3. The appellant sustained injury in a fall in service, with subsequent complaints of numbness in the fingers; bilateral carpal tunnel syndrome has been diagnosed clinically; arthritis of the hands or of the elbows has not been found. 4. Arthritis of the hands or of the elbows and another, unspecified, disorder of the elbows are not shown to exist. CONCLUSIONS OF LAW 1. The schedular criteria for a compensable rating for allergic rhinitis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.20, 4.97, Diagnostic Code 6501 (1994). 2. The schedular criteria for a 10 percent rating for asthma are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.97, Diagnostic Code 6602 (1994). 3. Bilateral carpal tunnel syndrome was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303(d) (1994). 4. Well-grounded claims for service connection for arthritis of the hands or of the elbows or for an unspecified disorder of the elbows have not been submitted. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION The appellant's claims are well grounded, except those for service connection alleging arthritis of the hands or elbows or unspecified disorder of the elbows, as is explained below. 38 U.S.C.A. § 5107(a) (West 1991). The appellant has responded to the RO's request that he provide a statement from his work supervisor regarding the affect of his service-connected disabilities on his work performance, stating his supervisor had not responded to his request for a statement. All other necessary development is complete. The duty to assist, Id., has been discharged. I. BACKGROUND All of the post-service medical records discussed below are from U.S. Navy medical facilities unless otherwise specified. A service entrance physical examination report is not of record. A reenlistment examination of July 1967 was negative for respiratory, musculoskeletal and neurologic findings. In December 1971, the appellant sustained a trauma of the right shoulder; subsequent examination noted reduced range of motion and "needle sticking" sensation on adduction and flexion; x-rays were negative; treatment was with analgesics. In April 1973, he was seen for complaints of nasal drip and watery eyes of one month's duration. On October 19, 1973, he sustained a fracture of the head of the second metacarpal of the right hand. On October 26, 1973, he was seen for cellulitis of the right elbow. An outpatient record of March 2, 1979, noted a fall sustained a week prior to seeking treatment. The appellant complained of "falling asleep" feelings in the third and fourth fingers of both hands, left more than right. A March 1979 medical history taken for extension of service showed he was taking Drixoral for allergy. In January 1982, he complained of pain behind the left shoulder blade, assessed as inflammation. In February 1984, he complained of numbness of the upper arm, assessed as tendonitis of the right shoulder. An emergency room record of April 3, 1984, noted a diagnosis of bronchitis with a reactive airways disease component seven days previously; the emergency treatment was for bronchitis. Allergy clinic records from June 1984 to April 1989 show repeated courses of immunotherapy and occasional emergency treatment for acute allergic reaction to various suspected allergens. Separation medical history and examination reports of February 2, 1989, noted allergies to penicillin, dust, weeds and grasses. Physical examination was negative for the lungs, chest and upper extremities. Allergy clinic records of January to April 1989 note that the appellant was doing well with allergy shots and had increased symptoms when they were stopped in January 1989. In April he denied any shortness of breath, wheezing or chest tightness except for two to three days during a recent Santa Ana wind. Pulmonary function test (PFT) revealed some obstruction. A VA examination report of August 1989 noted complaints of pain in the elbows when flexing the arm and of hand and finger pain when making a fist. The right shoulder was carried one inch lower than the left. Range of motion of all upper extremities was normal, without crepitus or muscular atrophy. There was full range of motion of the cervical spine. There was a finding of no acute arthritis in any joint. An allergy clinic record of September 1989 noted very mild bronchial asthma without recent symptoms and increased allergic rhinitis symptoms since discontinuing immunotherapy in January 1989. Of record are the reports of physical examinations done in October 1989 and October 1990 for the position of warehouseman. Examination found the respiratory tract clear in each instance, with good air exchange noted on the first. Neurologic findings were intact both times. The examination report form lists the functional requirements of the job and the environmental factors the employee must be fit to tolerate. In pertinent part, the functional factors are heavy lifting, moderate carrying, straight pulling, hand-over-hand pulling, pushing, reaching above shoulder, use of fingers, both hands required, walking, standing, kneeling, repeated bending, climbing with legs and arms. The environmental factors are work to be done outside and inside, excessive dampness and chilling, silica, asbestos, fumes, smoke or gases, solvents, grease and oils. The appellant sought emergency treatment on March 20, 1990, at a naval medical facility for an allergic reaction, thought to be to an allergy shot. Additional treatment records reveal he had been seen for bronchitis in February 1990, with minimal rhonchi of the lungs. The appellant testified at a hearing in March 1990. He stated he had four or five asthma attacks a month, with wheezing, shortness of breath, and tightness in the chest. He stated he has allergy symptoms including crusting of the eyes and nose in morning upon awakening. He stated he had three or four allergy attacks a month at work, which his supervisor accommodated by permitting him to change his work location and duties from the shop floor to the office. He stated he walks approximately 2 miles or 30 to 40 minutes in the evening, but gets winded and must stop for a time, but he completes the walk. He stated that asthma attacks at home cause him to curtail his activities until he takes medication. He stated it was hard to climb stairs, and his wife complains of his wheezing at night, which often caused him to sit up or get out of bed and sit for a time. He stated he got allergy shots approximately weekly, but that he had lost no time from work or school, which he attended part time evenings, either due to his disorders themselves or for treatment. In April 1990, the appellant complained of pain in the elbows of four or five years duration, and of paresthesia in the hands upon arising in the morning of about 7 months duration. X-rays of the appellant's elbows and cervical spine were negative. The impression was arthralgia of the hands and elbows. In a statement of April 12, 1990, R.V. Smith, reported that he knew of the appellant's fall of six or seven feet, landing on his back, in February 1979. He stated he was not an eye witness, but was the appellant's supervisor and had been called to the scene immediately after the accident. The appellant stated in his February 1990 Notice of Disagreement that when he fell in service, he landed on his back and that non- skid deck material became embedded in the backs of his arms from shoulders to hands and that he had had numb fingers, sore elbows and sore wrists ever since. A report from D.E. Silver, M.D., of September 1990, who the appellant saw regarding his elbow and hand problems, indicated an initial assessment of possible bilateral entrapment syndrome, probably elbows versus median nerve, and of possible cervical syndrome. A neurologic examination was negative, as was nerve a conduction study (NCS). Dr. Silver reported in October 1990 that an electromyogram (EMG) was negative, producing no evidence of denervation. A cervical spine x-ray was negative. An undated report stated that another NCS produced no evidence of abnormality whatsoever. Elbow pads and wrist splints were noted to reduce the symptoms. An x-ray of the cervical spine of April 1991 produced findings of degenerative disc disease of C5-C6 and C6-C7. There was no fracture or subluxation. An October 10, 1992 allergy clinic record noted the appellant's allergy symptoms were well controlled with allergy shots, but that symptoms increased without weekly shots. A 1989 skin test was noted as mostly negative, with reactivity to grasses only. On examination there were no acute symptoms. The chest was clear. The assessment was history suggestive of asthma but perfectly normal PFT (shows some lability) and allergic rhinitis, perennial, but positive skin test to grass only. Shots were to be continued. In a statement of March 11, 1993, the appellant stated that he got his allergy shots after work or on weekends. On VA examination in June 1992, the appellant complained of bilateral elbow numbness, described of pins and needles sensation, ongoing for seven or eight years. The appellant stated the numbness was worst upon arising and while writing. There was no complaint of weakness other than tiredness with the numbness. He reported typing and word processing among his activities in the past seven years. On examination motor responses were normal, reflexes were symmetric, coordination was normal and sensation was intact. There was a positive Phalen's sign, and bilaterally negative Tinel's sign over the wrist and elbow. The examiner commented that the symptoms, positive Phalen's sign and occupation made him almost certain of carpal tunnel syndrome. The examiner noted the past negative NCS and EMG, but felt that if repeated, they might be positive. He opined that even if repeat tests were negative, the appellant was probably one of those people who have electronegative carpal tunnel syndrome (CTS). On VA examination in July 1992, the appellant reported that he takes six Drixoral a week for allergy control, walks 1 1/2 to 2 miles in 30 to 40 minutes in the evening and develops dyspnea about half way through the walk. He reported use of an Alupent inhaler three or four times a week in the summer. He stated he was exposed to much dust while working as a warehouseman, which caused use of his inhaler up to five times a week at work, with prompt relief and return to work, normally. He said he had been a warehouseman for three years without missing work due to pulmonary symptoms. On examination his chest was clear to percussion and auscultation, without rales, rhonchi or wheezes. Breath sounds were normal. On specific evaluation, the examiner noted dyspnea on exertion as reported. The examiner interpreted a PFT report of July 2, 1992, presented by the appellant as essentially normal. The diagnosis was reactive airways disease, minimal/mild. On VA examination in November 1992, a NCS produced no electrophysiologic evidence of carpal tunnel syndrome or right cervical radiculopathy. The appellant has submitted an excerpt from a Military Operational Specialty Manual setting forth the functional requirements and duties of his occupation in the service, which included typing. II. ANALYSIS A. Increased Ratings The evidence regarding allergic rhinitis reveals ongoing treatment, but insignificant disability due to that disorder. There is no evidence of moderate secretion, which is a criterion for a 10 percent rating. See 38 C.F.R. § 4.97, Diagnostic Code 6501 (1994) (chronic atrophic rhinitis). Whereas allergic rhinitis is rated by analogy to atrophic rhinitis, 38 C.F.R. § 4.20 (1994), atrophy of the intranasal structure is not to be expected. See 38 C.F.R. § 4.21 (1994). However, the fact that the appellant's symptoms are repeatedly described as well controlled with immunotherapy and that he works in the environment described in the employment physical examination reports of record without missing any work is very strong evidence that he is not 10 percent disabled by allergic rhinitis. See 38 C.F.R. §§ 4.1, 4.2, 4.10 (1994). Finding credible his testimony of awakening with crusting of the nostrils and the need for ongoing medication and immunotherapy, those facts do not amount to a level of disability more nearly approximating 10 percent than noncompensable disablement. See 38 C.F.R. § 4.7 (1994). Consequently, the noncompensable rating for allergic rhinitis is correct. 38 C.F.R. § 4.31 (1994). The appellant shows minimal to mild reactive airways disease, i.e., asthma. The criteria for a 10 percent rating for bronchial asthma considered mild are "paroxysms of asthmatic type breathing (high pitched expiratory wheezing and dyspnea) occurring several times a year with no clinical findings between attacks." 38 C.F.R. § 4.97, Diagnostic Code 6602 (1994). The conditions described are not noted in any examination report since the inception of the appellant's claim. The episodes of wheezing to which he has testified are not shown by corroborating evidence to be of the quality particularly described in the rating criteria. If the episodes claimed by the appellant to occur five times a month were of the sort contemplated by the rating schedule, they would satisfy the frequency criterion for a 60 percent rating. The Board would expect to see some evidence of other of the criteria accompanying that level of frequency of attacks if the breathing reported by the appellant were of the type described in the rating schedule. It is credible, and consistent with the appellant's testimony that he never losses time from work due to his asthma, that the appellant has frequent, mild symptoms. His testimony is credible that he occasionally needs accommodation from his employer in the form of relief from general duties and assignment to office duties. See 38 C.F.R. § 4.10 (1994). Combined with the July 1992 VA examination finding that PFT results were labile, and the diagnosis of minimal to mild airways disease, the evidence can be seen to show a level of disability that more nearly approximates a compensable than a non-compensable degree of asthma. Consequently, a 10 percent rating for asthma is warranted. 38 C.F.R. § 4.7 (1994). Notably, absent any showing of moderate dyspnea on exertion between attacks, the frequency of asthmatic attacks, being mild, do not amount to a degree of disability commensurate with a rating higher than 10 percent. B. Service Connection for Bilateral Carpal Tunnel Syncrome The June 1992 VA diagnosis of bilateral carpal tunnel syndrome (CTS) is credible in light of the examiners careful explanation of the diagnosis, specifically notwithstanding the failure of electrodiagnostic confirmation. The service medical record shows that the appellant sustained a fall after which he complained of symptoms later found to be consistent with the diagnosis of CTS. It is immaterial that the appellant proffers two theories of the cause, acute injury in a fall and repetitive motion. The appellant is a lay person, not a medical expert, and his theories as to the causation of medical disorders is not probative evidence for or against his claim. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). More significant is that his post-service assertions that he has had numbness in the hands and bilateral elbow pain ever since the February 1973 accident appear inconsistent with the silence of the service medical records about such symptoms after February 1973, i.e., during another 16 years of service. However, the appellant did complain of hand and elbow symptoms within several months of separation from service, and there is no evidence whatsoever for an intercurrent cause. Moreover, the June 1992 VA examiner found his work history to be a significant factor in making the diagnosis of CTS. The evidence taken all together appears to be in equipoise, Gilbert v. Derwinski, 1 Vet.App. 49 (1990), and the appellant is entitled to the benefit of the doubt regarding the time of onset of the recently diagnosed CTS. 38 U.S.C.A. § 5107(b) (West 1991). Thus giving the appellant the benefit of the doubt, the Board concludes that all of the evidence, including that pertaining to service, establishes that the bilateral CTS diagnosed after service was incurred in service, and service- connection is warranted. C. Other Service Connection Claims The appellant's claims for service connection for arthritis of the hands or of the elbows or for other, unspecified, disorder of the elbows are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). There is no evidence of the onset of a chronic bilateral elbow disability in service, nor is one diagnosed at present. See Rabideau v. Derwinski, 2 Vet.App. 141 (1992) (a claim for a disability the appellant does not have cannot be well grounded). Also, there is no evidence or even current diagnosis of arthritis of the hands or of the elbows. Id. Whereas the appellant styled his claim as "service connection for a disability of the hands and elbows, claimed as arthritis or other, unspecified, disorder," the grant of service connection for bilateral CTS can be deemed as under the rubric of "other unspecified disorder" of the hands. The other elements of the claim, arthritis of the hands and elbows and "other, unspecified," disorder of the elbows, must be dismissed as not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). This decision is not final as to those elements of the appellant's claim that are not well grounded. Whereas the RO initially adjudicated and denied in January 1990 the claim as for service connection for arthritis of the elbows, in August 1990 denied a claim for service connection for arthritis of the hands and elbows, and in December 1992 denied a claim for service connection for hand and elbow condition, those decisions are void as to those claims and should be vacated, lest they be deemed final as to claims for service connection for arthritis of the hands or elbows or other, unspecified, condition of the elbows. See Grivois v. Brown, 6 Vet.App. 136 (1994); Grottveit v. Brown, 5 Vet.App. 91 (1993). ORDER An increased (compensable) rating for allergic rhinitis is denied. An increased rating of 10 percent for asthma is granted, subject to the regulations governing payment of monetary benefits. Service connection for bilateral carpal tunnel syndrome is granted. Claims for service connection for arthritis of the hands and of the elbows and for an unspecified disorder of the elbows are dismissed. The rating decisions of January and August 1990 and of December 1992 are vacated in that part which denied claims for service connection for arthritis of the hands and elbows and for an unspecified condition of the elbows. KENNETH R. ANDREWS, JR. Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.